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Hama Diallo A, Shahid ASMSB, Khan AF, Saleem AF, Singa BO, Gnoumou BS, Tigoi C, Achieng C, Bourdon C, Oduol C, Lancioni CL, Manyasi C, McGrath CJ, Maronga C, Lwanga C, Brals D, Ahmed D, Mondal D, Denno DM, Mangale DI, Chimezi E, Mbale E, Mupere E, Salauddin Mamun GM, Ouédraogo I, Berkley JA, Njirammadzi J, Mukisa J, Thitiri J, Walson JL, Jemutai J, Tickell KD, Shahrin L, Mallewa M, Hossain MI, Chisti MJ, Timbwa M, Mburu M, Ngari MM, Ngao N, Aber P, Harawa PP, Sukhtankar P, Bandsma RH, Bamouni RM, Molyneux S, Mwaringa S, Shaima SN, Ali SA, Afsana SM, Banu S, Ahmed T, Voskuijl WP, Kazi Z. Hospital readmission following acute illness among children 2-23 months old in sub-Saharan Africa and South Asia: a secondary analysis of CHAIN cohort. EClinicalMedicine 2024; 73:102676. [PMID: 38933099 PMCID: PMC11200276 DOI: 10.1016/j.eclinm.2024.102676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 05/13/2024] [Accepted: 05/20/2024] [Indexed: 06/28/2024] Open
Abstract
Background Children in low and middle-income countries remain vulnerable following hospital-discharge. We estimated the incidence and correlates of hospital readmission among young children admitted to nine hospitals in sub-Saharan Africa and South Asia. Methods This was a secondary analysis of the CHAIN Network prospective cohort enrolled between 20th November 2016 and 31st January 2019. Children aged 2-23 months were eligible for enrolment, if admitted for an acute illness to one of the study hospitals. Exclusions were requiring immediate resuscitation, inability to tolerate oral feeds in their normal state of health, had suspected terminal illness, suspected chromosomal abnormality, trauma, admission for surgery, or their parent/caregiver was unwilling to participate and attend follow-up visits. Data from children discharged alive from the index admission were analysed for hospital readmission within 180-days from discharge. We examined ratios of readmission to post-discharge mortality rates. Using models with death as the competing event, we evaluated demographic, nutritional, clinical, and socioeconomic associations with readmission. Findings Of 2874 children (1239 (43%) girls, median (IQR) age 10.8 (6.8-15.6) months), 655 readmission episodes occurred among 506 (18%) children (198 (39%) girls): 391 (14%) with one, and 115 (4%) with multiple readmissions, with a rate of: 41.0 (95% CI 38.0-44.3) readmissions/1000 child-months. Median time to readmission was 42 (IQR 15-93) days. 460/655 (70%) and 195/655 (30%) readmissions occurred at index study hospital and non-study hospitals respectively. One-third (N = 213/655, 33%) of readmissions occurred within 30 days of index discharge. Sites with fewest readmissions had the highest post-discharge mortality. Most readmissions to study hospitals (371/450, 81%) were for the same illness as the index admission. Age, prior hospitalisation, chronic conditions, illness severity, and maternal mental health score, but not sex, nutritional status, or physical access to healthcare, were associated with readmission. Interpretation Readmissions may be appropriate and necessary to reduce post-discharge mortality in high mortality settings. Social and financial support, training on recognition of serious illness for caregivers, and improving discharge procedures, continuity of care and facilitation of readmission need to be tested in intervention studies. We propose the ratio of readmission to post-discharge mortality rates as a marker of overall post-discharge access and care. Funding The Bill & Melinda Gates Foundation (OPP1131320).
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West M, Varnes A, Hudspeth M. Standardization of Pediatric Hematopoietic Stem Cell Transplant Patient Discharge to Reduce Readmission Rates. JOURNAL OF PEDIATRIC HEMATOLOGY/ONCOLOGY NURSING 2023; 40:432-439. [PMID: 37403518 DOI: 10.1177/27527530221147886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/06/2023]
Abstract
Background: The time period after a pediatric hematopoietic stem cell transplant (P-HSCT) is tenuous as the patient is severely immunocompromised and awaiting immune reconstitution. Managing activities of daily living and medication administration after discharge from the hospital requires 24-hour care placing a heavy burden on caregivers and patients. Patients who do not adhere to the posttransplant regimen are at a higher risk for hospital readmission within the first 30 days of initial discharge with serious potential for life-threatening complications. The objective of this project was to improve 30-day readmission rates and caregiver readiness for discharge through the implementation of an evidence-based discharge protocol for P-HSCT patients and caregivers. Methods: This quality improvement project included development and implementation of comprehensive Pediatric Blood & Marrow Transplant Guidelines and discharge protocol for patients who received an inpatient autologous or allogeneic HSCT and were scheduled for discharge from a 16-bed inpatient pediatric hematology-oncology unit of a children's hospital in the southeastern United States. Readmission rates were captured through the hospital-monitored system. Results: The comprehensive discharge protocol was implemented for six patients, and 30-day readmission rates decreased from 27.29% to 3.57% following the intervention. Discussion: Results suggest the combination of an evidence-based discharge protocol with a focus on caregiver readiness for discharge and a 24-hour Rooming-In period can influence caregiver confidence and reduce 30-day readmission rates after initial discharge from a P-HSCT.
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Affiliation(s)
- Meghan West
- Inpatient Pediatric Hematology-Oncology, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC, USA
| | - Ashley Varnes
- Clinical Practice Nurse Expert II, Cancer and Blood Disorders Unit, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC, USA
| | - Michelle Hudspeth
- Adult and Pediatric Blood & Marrow Transplantation, Pediatric Hematology/Oncology, Medical University of South Carolina Children's Hospital/Hollings Cancer Center, Charleston, SC, USA
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McDaniel CE, Lowry SJ, Ziniel SI, Freyleue S, Acquilano SC, Leyenaar JK. Development of the Pediatric Hospitalization Admission Survey of Experience (PHASE) Measure. Pediatrics 2023; 152:e2023061522. [PMID: 37584105 DOI: 10.1542/peds.2023-061522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 08/17/2023] Open
Abstract
BACKGROUND Although significant research is devoted to transitions of care at discharge, few measures assess the quality of transitions into the hospital. Our objective was to develop a caregiver-reported quality measure to evaluate the pediatric hospital admission experience. METHODS Measure development included: (1) adapting items from existing instruments; (2) an expert-consensus process to prioritize survey items; (3) cognitive pretesting with caregivers (n = 16); and (4) pilot testing revised items (n = 27). Subsequently, the survey was administered to caregivers at 2 children's hospitals and 1 general hospital from February 2020 through November 2021. Item reduction statistics and exploratory factor analysis were performed followed by confirmatory factor analysis. Domain scores were calculated using a top-box approach. Known-group validity and indices of model fit were evaluated. RESULTS The initial survey included 25 items completed by 910 caregivers. Following item reduction and the exploratory factor analysis, 14 items were mapped to 4 domains: (1) Patient and Family Engagement, (2) Information Sharing, (3) Effectiveness of Care Delivery, and (4) Timeliness of Care. The confirmatory factor analysis and validity testing supported the factor structure. Domain scores ranged from 49% (95% confidence interval, 46-53) for Timelines of Care to 81% (95% confidence interval, 65-84) for Patient and Family Engagement, with significant differences between general and children's hospitals in Information Sharing and Effectiveness of Care Delivery. CONCLUSIONS A 4-domain caregiver-reported hospital admission experience measure demonstrated acceptable validity and psychometric properties across children's and general hospitals. This measure can be used to evaluate the quality of transitions into the hospital and to focus quality improvement efforts.
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Affiliation(s)
- Corrie E McDaniel
- Seattle Children's Hospital, Seattle, Washington
- University of Washington, Seattle, Washington
| | - Sarah J Lowry
- Seattle Children's Hospital, Seattle, Washington
- University of Washington, Seattle, Washington
- Center for Biostatistics Epidemiology and Analytics, Seattle Children's Research Institute, Seattle, Washington
| | - Sonja I Ziniel
- Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colorado
| | - Seneca Freyleue
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Stephanie C Acquilano
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - JoAnna K Leyenaar
- The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
- Dartmouth Health Children's, Lebanon, New Hampshire
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Nelson A, Stuckey H, Snyder B, Van Scoy LJ, Daymont C, Irvin C, Wasserman E, Beck M. Provider Perspectives of Transitions of Care at a Tertiary Care Children's Hospital With a Hospitalist-Run Discharge Clinic. Clin Pediatr (Phila) 2023; 62:926-934. [PMID: 36726290 PMCID: PMC10986183 DOI: 10.1177/00099228221149279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Children's hospitals are discharging patients to home with increasingly complex outpatient needs, making safe transitions of care (ToCs) of vital importance. Our study involved a survey of both outpatient providers and pediatric hospitalists associated with our medical center to better describe providers' views on the ToC process. The survey included questions assessing views on patient care responsibilities, resource availability, our hospitalist-run postdischarge clinic (PDC), and comfort with telemedicine. Our hospitalists generally believed that primary care providers (PCPs) did not have adequate access to important ToC elements, whereas PCPs felt their access was adequate. Both provider types felt it was the inpatient team's responsibility to manage patient events between discharge and PCP follow-up and that a hospitalist-run PDC may reduce interim emergency room visits. This study challenges perceptions about the ToC process in children and describes a generalizable approach to assessing provider perceptions surrounding the ToC within individual health systems.
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Affiliation(s)
- Abigail Nelson
- Penn State Children’s Hospital, Department of Pediatrics
| | - Heather Stuckey
- Penn State Hershey College of Medicine; Department of Medicine
| | - Bethany Snyder
- Penn State Hershey College of Medicine; Department of Medicine
| | | | - Carrie Daymont
- Penn State Children’s Hospital, Department of Pediatrics
- Penn State Hershey College of Medicine, Department of Public Health Sciences
| | | | - Emily Wasserman
- Penn State Hershey College of Medicine, Department of Public Health Sciences
| | - Michael Beck
- Penn State Children’s Hospital, Department of Pediatrics
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Bucholz EM, Hall M, Harris M, Teufel RJ, Auger KA, Morse R, Neuman MI, Peltz A. Annual Variation in 30-Day Risk-Adjusted Readmission Rates in U.S. Children's Hospitals. Acad Pediatr 2023; 23:1259-1267. [PMID: 36581101 DOI: 10.1016/j.acap.2022.12.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 12/02/2022] [Accepted: 12/17/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE Reducing pediatric readmissions has become a national priority; however, the use of readmission rates as a quality metric remains controversial. The goal of this study was to examine short-term stability and long-term changes in hospital readmission rates. METHODS Data from the Pediatric Health Information System were used to compare annual 30-day risk-adjusted readmission rates (RARRs) in 47 US children's hospitals from 2016 to 2017 (short-term) and 2016 to 2019 (long-term). Pearson correlation coefficients and weighted Cohen's Kappa statistics were used to measure correlation and agreement across years for hospital-level RARRs and performance quartiles. RESULTS Median (IQR) 30-day RARRs remained stable from 7.7% (7.0-8.3) in 2016 to 7.6% (7.0-8.1) in 2019. Individual hospital RARRs in 2016 were strongly correlated with the same hospital's 2017 rate (R2 = 0.89 [95% confidence interval (CI) 0.80-0.94]) and moderately correlated with those in 2019 (R2 = 0.49 [95%CI 0.23-0.68]). Short-term RARRs (2016 vs 2017) were more highly correlated for medical conditions than surgical conditions, but correlations between long-term medical and surgical RARRs (2016 vs 2019) were similar. Agreement between RARRs was higher when comparing short-term changes (0.73 [95%CI 0.59-0.86]) than long-term changes (0.45 [95%CI 0.27-0.63]). From 2016 to 2019, RARRs increased by ≥1% in 7 (15%) hospitals and decreased by ≥1% in 6 (13%) hospitals. Only 7 (15%) hospitals experienced reductions in RARRs over the short and long-term. CONCLUSIONS Hospital-level performance on RARRs remained stable with high agreement over the short-term suggesting stability of readmission measures. There was little evidence of sustained improvement in hospital-level performance over multiple years.
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Affiliation(s)
- Emily M Bucholz
- Division of Cardiology (EM Bucholz), Children's Hospital of Colorado and the University of Colorado School of Medicine, Aurora.
| | - Matt Hall
- Children's Hospital Association (M Hall and M Harris), Lenexa, Kans
| | - Mitch Harris
- Children's Hospital Association (M Hall and M Harris), Lenexa, Kans
| | - Ronald J Teufel
- Department of Pediatrics, Medical University of South Carolina (RJ Teufel), Charleston
| | - Katherine A Auger
- Division of Hospital Medicine and James M. Anderson Center for Healthcare Improvement (KA Auger), Cincinnati Children's Hospital Medical Center, Ohio
| | - Rustin Morse
- Center for Clinical Excellence, Nationwide Children's Hospital (R Morse), Columbus, Ohio
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital (MI Neuman), Mass
| | - Alon Peltz
- Center for Healthcare Research in Pediatrics, Department of Population Medicine, Harvard Medical School and Harvard Pilgrim Healthcare Institute, Department of Pediatrics (A Peltz), Boston Children's Hospital, Mass
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Pattnaik P, Nafday S, Angert R. Neonatal Intensive Care Unit to Home Discharge Communication: A Quality Improvement Project. Pediatr Qual Saf 2023; 8:e669. [PMID: 37434592 PMCID: PMC10332829 DOI: 10.1097/pq9.0000000000000669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 06/06/2023] [Indexed: 07/13/2023] Open
Abstract
Neonatal intensive care unit (NICU) graduates require complex services after discharge. The NICU discharge process at Children's Hospital at Montefiore-Weiler, Bronx, NY (CHAM-Weiler) lacked a system for routine primary care provider (PCP) notification. Here, we describe a quality improvement project to improve communication with PCPs to ensure communication of critical information and plans. Methods We assembled a multidisciplinary team and collected baseline data on discharge communication frequency and quality. We used quality improvement tools to implement a higher-quality system. The outcome measure was the successful delivery of a standardized notification and discharge summary to a PCP. We collected qualitative data through multidisciplinary meetings and direct feedback. The balancing measures comprised additional time spent during the discharge process and relaying erroneous information. We used a run chart to track progress and drive change. Results Baseline data indicated that 67% of PCPs did not receive notifications before discharge, and when PCPs did receive notifications, the discharge plans were unclear. PCP feedback led to proactive electronic communication and a standardized notification. The key driver diagram allowed the team to design interventions that led to sustainable change. After multiple Plan-Do-Study-Act cycles, delivery of electronic PCP notifications occurred more than 90% of the time. Surveys of pediatricians who received notifications indicated that the notifications were highly valued and aided in the transition of care for these at-risk patients. Conclusion A multidisciplinary team, including community pediatricians, was key to improving the rate of PCP notification of NICU discharge to more than 90% and transmitting higher-quality information.
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Affiliation(s)
- Priyam Pattnaik
- From the Department of Pediatrics, Division of Neonatology, Connecticut Children’s Medical Center, Hartford, Conn
| | - Suhas Nafday
- Department of Pediatrics, Division of Neonatology, The Children’s Hospital at Montefiore and Albert Einstein College of Medicine, Bronx, N.Y
| | - Robert Angert
- Department of Pediatrics, Division of Neonatology, New York University Langone Medical Center, New York, N.Y
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Hovey SW, Cho HJ, Kain C, Sauer HE, Smith CJ, Thomas CA. Pharmacist-Led Discharge Transitions of Care Interventions for Pediatric Patients: A Narrative Review. J Pediatr Pharmacol Ther 2023; 28:180-191. [PMID: 37303760 PMCID: PMC10249976 DOI: 10.5863/1551-6776-28.3.180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/28/2022] [Indexed: 06/13/2023]
Abstract
Transitions of care (TOC) before, during, and after hospital discharge are an opportune setting to optimize medication management. The quality standards for pediatric care transitions, however, are lacking, leading to reduced health outcomes in children. This narrative review characterizes the pediatric populations that would benefit from focused, TOC interventions. Different types of medication-focused TOC interventions during hospital discharge are described, including medication reconciliation, education, access, and adherence tools. Various TOC intervention delivery models following hospital discharge are also reviewed. The goal of this narrative review is to help pediatric pharmacists and pharmacy leaders better understand TOC interventions and integrate them into the hospital discharge process for children and their caregivers.
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Affiliation(s)
- Sara W. Hovey
- Department of Pharmacy Practice (SWH), University of Illinois at Chicago, College of Pharmacy, Chicago, IL
| | - Hae Jin Cho
- Department of Pharmacotherapy (HJC), College of Pharmacy, The University of North Texas Health Science Center at Fort Worth, Fort Worth, TX
| | - Courtney Kain
- Department of Pharmacy (CK), Nemours Children's Hospital, Wilmington, DE
| | - Hannah E. Sauer
- Department of Pharmacy (HES), Texas Children's Hospital, Houston, TX
| | - Christina J. Smith
- Department of Pharmacy (CJS), Loma Linda University Children's Hospital, Loma Linda, CA
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Haimowitz RL, Halley TV, Driskill C, Kendall M, Parikh K. Implementing a Post-Discharge Telemedicine Service Pilot to Enhance the Hospital to Home Transition. Hosp Pediatr 2023; 13:508-519. [PMID: 37212032 DOI: 10.1542/hpeds.2022-006989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
OBJECTIVES The objectives of this study are to (1) describe our postdischarge telemedicine program and (2) evaluate program implementation. METHODS At our single-center tertiary care children's hospital, we launched our postdischarge telemedicine program in April 2020. We used the Template for Intervention Description and Replication framework to describe our pilot program and Proctor's conceptual framework to evaluate implementation over a 9-month period. Retrospective chart review was conducted. Descriptive analyses were used to compare demographics and health care reutilization rates across patients. Implementation outcomes included adoption (rate of scheduled visits) and feasibility (rate of completed visits). Effectiveness outcomes included the rate of postdischarge issues and unscheduled healthcare utilization. RESULTS We established a postdischarge telemedicine program for a general pediatric population that ensured follow-up at a time when in-person evaluation was limited because of the coronavirus disease 2019 pandemic. For implementation evaluation, we included all 107 patients in the pilot program. Adoption was 100% and feasibility was 58%. Eighty-two percent of patients completing a visit reported one or more postdischarge issues. There was no difference in health system reutilization between those who completed a visit and those who did not. CONCLUSIONS Implementation of a postdischarge telemedicine service is achievable and promotes early detection of failures in the hospital to home transition. Directions for future study will include rigorous program evaluation via telemedicine program assessment tools and sustainability efforts that build upon known implementation and health service outcomes.
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Affiliation(s)
- Rachel L Haimowitz
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia
| | - Tina V Halley
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia
| | - Christina Driskill
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia
| | - Morgan Kendall
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia
- Section of Hospital Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kavita Parikh
- Division of Hospital Medicine, Children's National Hospital, Washington, District of Columbia
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Valença-Feitosa F, Santos MRD, Carvalho GAC, Alcantara TDS, Oliveira Filho ADD, Lyra-Jr DPD. Cost-effectiveness of medication reconciliation performed by a pharmacist in pediatrics of a hospital: A randomized clinical trial protocol linked to a pharmacoeconomic study. Res Social Adm Pharm 2023; 19:550-556. [PMID: 36456409 DOI: 10.1016/j.sapharm.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Accepted: 10/29/2022] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Each patient admitted to the hospital is subject to one medication error per day, since the occurrence of this one with the potential to cause harm is three times more common in pediatric hospitalized patients than in adults. These harms can result from inaccurate or incomplete drug use histories when patients undergo a clinical evaluation, which jeopardizes patient safety and compromises hospitalization costs. Thus, medication reconciliation (MC) emerges as a possible solution to avoid the occurrence of these in pediatric patients and directly contributes to reducing costs in the hospital environment and increasing quality of life). Therefore, this study proposes to determine whether pharmacist-led medication reconciliation is a cost-effective strategy to improve health outcomes in pediatric patients. METHODS A randomized clinical trial will be carried out, over eight months, to carry out the cost analysis. Micro-costing pharmacoeconomic model through a questionnaire and clinical interview to collect the variables necessary for the study and comparison of the control and intervention groups. Participants in this study will be children aged 0 days to 12 years, admitted to the hospital. The perspective adopted will be that of the hospital. To assess the economic outcomes of MC, the cost-effect pairs will be categorized and visually represented in the cost-effectiveness plan to compare the intervention and control groups. Monte Carlo simulation and univariate sensitivity analysis will be performed to test the robustness of the findings. ETHICS AND DISSEMINATION The clinical trial was approved by the Research Ethics Committee of the Federal University of Sergipe (CAAE: 19625319.6.0000.5546 and opinion number: 3,630,579). This protocol fully adhered to the recommendations of the 2010 CONSORT Declaration and was registered in the Brazilian Registry of Clinical Trials (ReBEC): RBR-25dnqsk.
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Affiliation(s)
- Fernanda Valença-Feitosa
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Federal, Sergipe, Cidade Universitária "Prof. José Aloísio Campos", Jardim Rosa Elze, São Cristóvão, CEP: 49100-000, Brazil.
| | - Millena Rakel Dos Santos
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Federal, Sergipe, Cidade Universitária "Prof. José Aloísio Campos", Jardim Rosa Elze, São Cristóvão, CEP: 49100-000, Brazil.
| | - Gabriela Andrade Conrado Carvalho
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Federal, Sergipe, Cidade Universitária "Prof. José Aloísio Campos", Jardim Rosa Elze, São Cristóvão, CEP: 49100-000, Brazil.
| | - Thaciana Dos Santos Alcantara
- René Rachou Research Center/Oswaldo Cruz Foundation, Minas Gerais, Av. Augusto de Lima, 1715 - Barro Preto, Belo Horizonte, 30190-002, Brazil.
| | - Alfredo Dias de Oliveira Filho
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Federal, Sergipe, Cidade Universitária "Prof. José Aloísio Campos", Jardim Rosa Elze, São Cristóvão, CEP: 49100-000, Brazil.
| | - Divaldo Pereira de Lyra-Jr
- Laboratory of Teaching and Research in Social Pharmacy (LEPFS), Federal, Sergipe, Cidade Universitária "Prof. José Aloísio Campos", Jardim Rosa Elze, São Cristóvão, CEP: 49100-000, Brazil.
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Kulawiak J, Miller JA, Hovey SW. Incidence of Medication-Related Problems Following Pediatric Epilepsy Admissions. Pediatr Neurol 2023; 142:10-15. [PMID: 36848725 DOI: 10.1016/j.pediatrneurol.2023.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 01/28/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND An estimated 26% to 33% of pediatric patients have at least one medication error at hospital discharge. Pediatric patients with epilepsy may be at greater risk due to complex medication regimens and frequent hospitalizations. This study aims to quantify the proportion of pediatric patients with epilepsy experiencing medication problems after discharge and determine if medication education decreases these problems. METHODS This was a retrospective cohort study including pediatric patients with epilepsy-related hospital admissions. Cohort 1 consisted of a control group, and cohort 2 consisted of patients who received discharge medication education, enrolled in a 2:1 ratio. The medical record was reviewed from hospital discharge to outpatient neurology follow-up to identify medication problems that occurred. The primary outcome was the difference in proportion of medication problems between the cohorts. Secondary outcomes were incidence of medication problems with harm potential, overall incidence of medication problems, and 30-day epilepsy-related readmissions. RESULTS A total of 221 patients were included (163 in the control cohort and 58 in the discharge education cohort) with balanced demographics. The incidence of medication problems was 29.4% in the control cohort and 24.1% in the discharge education cohort (P = 0.44). The most common problems were mismatched dose or direction. Medication problems with harm potential were 54.2% in the control group and 28.6% in the discharge education cohort (P = 0.131). CONCLUSION Medication problems and their harm potential were lower in the discharge education cohort, but the difference was not significant. This demonstrates education alone may not be enough to impact medication error rates.
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Affiliation(s)
- Jessica Kulawiak
- Department of Pharmacy, Rush University Medical Center, Chicago, Illinois.
| | | | - Sara W Hovey
- Department of Pharmacy, Rush University Medical Center, Chicago, Illinois
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Buczkowski A, Craig W, Holmes R, Allen D, Longnecker L, Kondrad M, Carr A, Turchi R, Gage S, Osorio SN, Cooperberg D, Mallory L. Factors Correlated With Successful Pediatric Post-Discharge Phone Call Attempt and Connection. Hosp Pediatr 2023; 13:47-54. [PMID: 36514893 DOI: 10.1542/hpeds.2022-006675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Postdischarge phone calls can identify discharge errors and gather information following hospital-to-home transitions. This study used the multisite Project IMPACT (Improving Pediatric Patient Centered Care Transitions) dataset to identify factors associated with postdischarge phone call attempt and connectivity. METHODS This study included 0- to 18-year-old patients discharged from 4 sites between January 2014 and December 2017. We compared demographic and clinical factors between postdischarge call attempt and no-attempt and connectivity and no-connectivity subgroups and used mixed model logistic regression to identify significant independent predictors of call attempt and connectivity. RESULTS Postdischarge calls were attempted for 5528 of 7725 (71.6%) discharges with successful connection for 3801 of 5528 (68.8%) calls. Connection rates varied significantly among sites (52% to 79%, P < .001). Age less than 30 days (P = .03; P = .01) and age 1 to 6 years (P = .04; P = .04) were independent positive predictors for both call attempt and connectivity, whereas English as preferred language (P < .001) and the chronic noncomplex clinical risk group (P = .02) were independent positive predictors for call attempt and connectivity, respectively. In contrast, readmission within 3 days (P = .004) and federal or state payor (P = .02) were negative independent predictors for call attempt and call connectivity, respectively. CONCLUSIONS This study suggests that targeted interventions may improve postdischarge call attempt rates, such as investment in a reliable call model or improvement in interpreter use, and connectivity, such as enhanced population-based communication.
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Affiliation(s)
- Amy Buczkowski
- Department of Pediatrics, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, Maine
| | - Wendy Craig
- Maine Medical Center Research Institute, Scarborough, Maine
| | - Rebekah Holmes
- Midwestern University - Chicago College of Osteopathic Medicine, Downers Grove, Illinois
| | - Dannielle Allen
- University of New England College of Osteopathic Medicine, Biddeford, Maine
| | - Lee Longnecker
- Department of Pediatrics, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, Maine
| | - Monica Kondrad
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Ann Carr
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Renee Turchi
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Sandra Gage
- Department of Child Health, University of Arizona College of Medicine-Phoenix, Phoenix Children's Hospital, Phoenix, Arizona
| | - Snezana Nena Osorio
- Department of Pediatrics, Weill Cornell Medicine, Komansky Children's Hospital, New York Presbyterian Hospital, New York, New York
| | - David Cooperberg
- Department of Pediatrics, Drexel University College of Medicine, St. Christopher's Hospital for Children, Philadelphia, Pennsylvania
| | - Leah Mallory
- Department of Pediatrics, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, Maine
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12
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Vaz LE, Jungbauer RM, Jenisch C, Austin JP, Wagner DV, Everest SJ, Libak AJ, Harris MA, Zuckerman KE. Caregiver Experiences in Pediatric Hospitalizations: Challenges and Opportunities for Improvement. Hosp Pediatr 2022; 12:1073-1080. [PMID: 36412061 DOI: 10.1542/hpeds.2022-006645] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There are limited qualitative data describing general pediatric hospitalizations through the caregivers' lens, and most focus on one particular challenge or time during the hospitalization. This qualitative study aimed to address a gap in the description of the breadth and depth of personal challenges caregivers may face during the entire hospitalization, irrespective of severity of patient illness or diagnosis, and explored caregiver-suggested interventions. METHODS Caregivers of pediatric patients on the hospitalist service at a Pacific Northwest children's hospital were interviewed to explore their hospitalization experience and solicit feedback for potential interventions. Content was coded iteratively using a framework analysis until thematic saturation was met. Findings were triangulated through 2 focus groups, 1 with parent advisors and the other with hospital physicians and nurses. RESULTS Among 14 caregivers (7 each of readmitted and newly admitted patients) and focus group participants, emergent domains on difficulties faced with their child's hospitalization were anchored on physiologic (sleep, personal hygiene, and food), psychosocial (feelings of isolation, mental stress), and communication challenges (information flow between families and the medical teams). Caregivers recognized that addressing physiologic and psychosocial needs better enabled them to advocate for their child and suggested interventions to ameliorate hospital challenges. CONCLUSIONS Addressing physiologic and psychosocial needs may reduce barriers to caregivers optimally caring and advocating for their child. Downstream consequences of unaddressed caregiver challenges should be explored in relation to participation in hospital care and confidence in shared decision-making, both vital components for optimization of family-centered care.
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Affiliation(s)
- Louise E Vaz
- Department of Pediatrics, Doernbecher Children's Hospital
| | - Rebecca M Jungbauer
- Pacific Northwest Evidence-Based Practice Center, Oregon Health and Science University, Portland, Oregon
| | - Celeste Jenisch
- Department of Pediatrics, Doernbecher Children's Hospital.,Build Exito Program, Portland State University, Portland, Oregon
| | - Jared P Austin
- Department of Pediatrics, Doernbecher Children's Hospital
| | - David V Wagner
- Department of Pediatrics, Doernbecher Children's Hospital
| | - Steven J Everest
- Build Exito Program, Portland State University, Portland, Oregon
| | - Alyssa J Libak
- Build Exito Program, Portland State University, Portland, Oregon
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13
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Paydar-Darian N, Stack AM, Volpe D, Gerling MJ, Seneski A, Eisenberg MA, Hickey E, Toomey Lindsay K, Moriarty L, Hudgins JD, Falvo F, Portillo EN, Creedon JK, Perron CE. Improving Discharge Safety in a Pediatric Emergency Department. Pediatrics 2022; 150:189722. [PMID: 36222092 DOI: 10.1542/peds.2021-054307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/15/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Discharge from the emergency department (ED) involves a complex series of steps to ensure a safe transition to home and follow-up care. Preventable, discharge-related serious safety events (SSEs) in our ED highlighted local vulnerabilities. We aimed to improve ED discharge by implementing a standardized discharge process with emphasis on multidisciplinary communication and family engagement. METHODS At a tertiary children's hospital, we used the model for improvement to revise discharge care. Interventions included a new discharge checklist, a provider huddle emphasizing discharge vital signs, and a scripted discharge review of instructions with families. We used statistical process control to evaluate performance. Primary outcomes included elimination of preventable, discharge-related SSEs and Press Ganey survey results assessing caregiver information for care of child at home. A secondary outcome was number of days between preventable low-level (near-miss, no or minimal harm) events. Process measures included discharge checklist adoption and vital sign acquisition. Balancing measures were length of stay (LOS) and return rates. RESULTS Over the study period, there were no preventable SSEs and low-level event frequency improved to a peak of >150 days between events. Press Ganey responses regarding quality of discharge information did not change (62%). Checklist use was rapidly adopted, reaching 94%. Vital sign acquisition increased from 67% to 83%. There was no change in the balancing measures of median LOS or return visit rates. CONCLUSIONS The development and implementation of a standardized discharge process led to the elimination of reported discharge-related events, without increasing LOS or return visits.
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Affiliation(s)
- Niloufar Paydar-Darian
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Anne M Stack
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Diana Volpe
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Megan J Gerling
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Annie Seneski
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Matthew A Eisenberg
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Eileen Hickey
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Katie Toomey Lindsay
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Laura Moriarty
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Joel D Hudgins
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Francine Falvo
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Elyse N Portillo
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts.,Section of Emergency Medicine, Texas Children's Hospital and Baylor College of Medicine, Houston, Texas
| | - Jessica K Creedon
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Catherine E Perron
- Division of Emergency Medicine, Boston Children's Hospital and Harvard Medical School, Boston, Massachusetts
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14
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Diop H, Cui X, Nielsen T, Peacock-Chambers E, Gupta M. Length of Stay Among Infants with Neonatal Abstinence Syndrome and Risk of Hospital Readmission. Matern Child Health J 2022; 26:2020-2029. [PMID: 35907127 DOI: 10.1007/s10995-022-03481-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/17/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To assess whether a shorter length of stay (LOS) is associated with a higher risk of readmission among newborns with neonatal abstinence syndrome (NAS) and examine the risk, causes, and characteristics associated with readmissions among newborns with NAS, using a longitudinally linked population-based database. METHODS Our study sample included full-term singletons with NAS (n = 4,547) and without NAS (n = 327,836), born in Massachusetts during 2011-2017. We used log-binomial regression models to estimate the crude risk ratios (cRRs) and adjusted RRs with 95% confidence intervals (CI) of the association between LOS and readmissions, controlling for maternal age, race/ethnicity, education, marital status, insurance, method of delivery, birthweight, adequacy of prenatal care, smoking, and abnormal conditions of newborn. RESULTS Compared with infants without NAS, infants with NAS had a non-significantly higher risk of readmission within 2-42 days (2.8% vs. 2.5%; p = 0.17) and a significantly higher risk of readmission within 43-182 days (2.7% vs. 1.8%; p < 0.001). The risk of readmission within 2-42 days was significantly higher among infants with NAS with a LOS of 0-6 days compared to a LOS of 14-20 days (reference group) (aRR: 2.1; 95% CI: 1.2-3.5). No significant differences in readmission rates between 43 and 182 days were observed across LOS categories. CONCLUSIONS Among infants with NAS, a LOS of 0-6 days was associated with a significantly higher risk of readmission within 2-42 days of discharge compared to a longer LOS.
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Affiliation(s)
- Hafsatou Diop
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108, USA.
| | - Xiaohui Cui
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108, USA
| | - Timothy Nielsen
- Massachusetts Department of Public Health, 250 Washington Street, 6th Floor, Boston, MA, 02108, USA
| | | | - Munish Gupta
- Beth Israel Deaconess Medical Center, Boston, MA, USA
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15
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Vaughan L, Neary T, Manicone P. Improving Timely Discharges Through Nurse-Initiated Conditional Discharge Orders. Hosp Pediatr 2022; 12:600-606. [PMID: 35502605 DOI: 10.1542/hpeds.2021-006220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Hospitalized patients are often medically ready for discharge before actual time of discharge. Delays are multifactorial, including medical staff workflow, knowledge, culture, and system issues. Identifying discharge criteria in a nurse-initiated conditional discharge (NICD) order facilitates a nurse-initiated discharge, creates a shared mental model for early discharge readiness, and improves workflow delays. The objective was to increase the percentage of morning discharges from 6% to 11% on the hospitalist intervention team, sustaining 11% for 6 months. METHODS All patients admitted to a hospitalist service (intervention team) were targeted from July 2018 through March 2020. The primary outcome measure was percentage of morning discharges (6:00 am-12:00 pm). Quality improvement methodology was used to initiate bundled interventions, including NICD order use and education, written tool dissemination, and weekly e-mail reminders (PDSA1). Continued education with dissemination of an instructional module and a resident champion were established to improve resident hesitancy (PDSA2). RESULTS Special cause variation was observed for the primary outcome after PDSA2 with a positive shift in the number of early discharges. Special cause variation was observed in the process measure after PDSA1 with 6 points above the mean. CONCLUSIONS Through NICD orders, written tool dissemination, and a resident champion to encourage system-wide culture change, patients were discharged earlier, improving patient flow.
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Affiliation(s)
| | - Tara Neary
- Children's National Hospital, Washington, District of Columbia
| | - Paul Manicone
- Children's National Hospital, Washington, District of Columbia
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16
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Discharge interventions from inpatient child and adolescent mental health care: a scoping review. Eur Child Adolesc Psychiatry 2022; 31:857-878. [PMID: 32886222 PMCID: PMC9209379 DOI: 10.1007/s00787-020-01634-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 08/26/2020] [Indexed: 11/26/2022]
Abstract
The post-discharge period is an extremely vulnerable period for patients, particularly for those discharged from inpatient children and adolescent mental health services (CAMHS). Poor discharge practices and discontinuity of care can put children and youth at heightened risk for readmission, among other adverse outcomes. However, there is limited understanding of the structure and effectiveness of interventions to facilitate discharges from CAMHS. As such, a scoping review was conducted to identify the literature on discharge interventions. This scoping review aimed to describe key components, designs, and outcomes of existing discharge interventions from CAMHS. Nineteen documents were included in the final review. Discharge interventions were extracted and summarized for pre-discharge, post-discharge, and bridging elements. Results of this scoping review found that intervention elements included aspects of risk assessment, individualized care, discharge preparation, community linkage, psychoeducation, and follow-up support. Reported outcomes of discharge interventions were also extracted and included positive patient and caregiver satisfaction, improved patient health outcomes, and increased cost effectiveness. Literature on discharge interventions from inpatient CAMHS, while variable in structure, consistently underscore the role of such interventions in minimizing patient and family vulnerability post-discharge. However, findings are limited by inadequate reporting and heterogeneity across studies. There is a need for further research into the design, implementation, and evaluation of interventions to support successful discharges from inpatient child and adolescent mental health care.
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17
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Dworsky ZD, Rhee KE, Patel AR, McMahon MK, Pierce HC, Stucky Fisher E. Assessing Parental Discharge Readiness by Using the Ticket to Home Survey Tool. Hosp Pediatr 2022; 12:85-93. [PMID: 34889352 DOI: 10.1542/hpeds.2021-005832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Ticket to Home (TTH), a survey tool designed to assess parental comprehension of their child's hospitalization and postdischarge care needs, allows providers to address knowledge gaps before discharge. Our goal was to evaluate the impact of TTH on parents' retention of discharge teaching. METHODS In this pilot study, we enrolled a convenience sample of families admitted to pediatric hospital medicine and randomly assigned families on the basis of team assignment. The intervention group received TTH before discharge. The control group received usual care (without TTH survey tool). Both groups were sent a survey 24 to 72 hours postdischarge to assess parental understanding of discharge teaching. A senior-level provider also completed a survey; responses were compared with evaluate parent level of understanding. Descriptive statistics and logistic regression were used for analysis. RESULTS Although 495 parents consented to participate, only 100 completed the necessary surveys (41 intervention and 59 control). Both groups showed high parent-provider concordance regarding reason for admission (92.7% intervention versus 86.4% control; P = .33). The intervention group had significantly higher concordance for return precautions (90.2% vs 58.2%; P < .001), which remained significant when controlling for covariates (odds ratio 6.24, 95% confidence interval 1.78-21.93). Most parents in the intervention group felt sharing TTH responses with their medical team was beneficial (95.0%). CONCLUSIONS Parents who received TTH before discharge were more likely to accurately recall return precautions and valued sharing TTH results with the team. Given that response bias may have affected pilot results, additional studies in which researchers use larger samples with more diverse patient populations is required.
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Affiliation(s)
- Zephyr D Dworsky
- Rady Children's Hospital San Diego and Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California San Diego, San Diego, California
| | - Kyung E Rhee
- Rady Children's Hospital San Diego and Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California San Diego, San Diego, California
| | - Aarti R Patel
- Rady Children's Hospital San Diego and Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California San Diego, San Diego, California
| | - Molly K McMahon
- Rady Children's Hospital San Diego and Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California San Diego, San Diego, California.,College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California
| | - Heather C Pierce
- Rady Children's Hospital San Diego and Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California San Diego, San Diego, California
| | - Erin Stucky Fisher
- Rady Children's Hospital San Diego and Division of Pediatric Hospital Medicine, Department of Pediatrics, University of California San Diego, San Diego, California
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18
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Choe AY, Schondelmeyer AC, Thomson J, Schwieter A, McCann E, Kelley J, Demeritt B, Unaka NI. Improving Discharge Instructions for Hospitalized Children With Limited English Proficiency. Hosp Pediatr 2021; 11:1213-1222. [PMID: 34654727 DOI: 10.1542/hpeds.2021-005981] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Patients with limited English proficiency (LEP) have increased risk of adverse events after hospitalization. At our institution, LEP families did not routinely receive translated discharge instructions in their preferred language. Our objective for this study was to increase the percentage of patients with LEP on the hospital medicine (HM) service receiving translated discharge instructions from 12% to 80%. METHODS Following the Model for Improvement, we convened an interdisciplinary team that included HM providers, pediatric residents, language access services staff, and nurses to design and test interventions aimed at key drivers through multiple plan-do-study-act cycles. Interventions addressed the translation request process, care team education, standardizing discharge instructions for common conditions, and identification and mitigation of failures. We used established rules for analyzing statistical process control charts to evaluate the percentage of patients with translated discharge instructions for all languages and for Spanish. RESULTS During the study period, 540 patients with LEP were discharged from the HM service. Spanish was the preferred language for 66% of patients with LEP. The percentage of patients with LEP who received translated discharge instructions increased from 12% to 50% in 3 months and to 77% in 18 months. For patients whose preferred language was Spanish, the percentage increased from 16% to 69% in 4 months and to 96% in 18 months. CONCLUSIONS Interventions targeting knowledge of the translation process and standardized Spanish discharge instructions were associated with an increased percentage of families receiving translated discharge instructions. Future work will be used to assess the impact of these interventions on postdischarge disparities, including emergency department revisits and readmissions.
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Affiliation(s)
- Angela Y Choe
- Division of Hospital Medicine, Children's Hospital Los Angeles, Los Angeles, California.,Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Amanda C Schondelmeyer
- Division of Hospital Medicine.,James M. Anderson Center for Health Systems Excellence.,Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joanna Thomson
- Division of Hospital Medicine.,Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Erin McCann
- Pediatric Residency Program, and Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - Brenda Demeritt
- Pediatric Residency Program, and Patient Services, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Ndidi I Unaka
- Division of Hospital Medicine .,Department of Pediatrics, College of Medicine, University of Cincinnati and Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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19
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Clark NA, Simmons J, Etzenhouser A, Pallotto EK. Improving Outpatient Provider Communication for High-Risk Discharges From the Hospitalist Service. Hosp Pediatr 2021; 11:1033-1048. [PMID: 34526327 DOI: 10.1542/hpeds.2020-005421] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
BACKGROUND Patients are at risk for adverse events during inpatient-to-outpatient transitions of care. Previous improvement work has been targeted at this care transition, but gaps in discharge communication still exist. We aimed to increase documentation of 2-way communication between hospitalists and primary care providers (PCPs) for high-risk discharges from pediatric hospital medicine (PHM) services from 7% to 60% within 30 months. METHODS A3 improvement methodology was used. A list of high-risk discharge communication criteria was developed through engagement of PCPs and hospitalists. A driver diagram guided interventions. The outcome measure was documentation of successful 2-way communication with the PCP. Any documented 2-way discharge communication attempt was the process measure. Via a survey, hospitalist satisfaction with the discharge communication expectation served as the balancing measure. All patients discharged from PHM services meeting ≥1 high-risk criterion were included. Statistical process control charts were used to assess changes over time. RESULTS There were 3241 high-risk discharges (442 baseline: November 2017 to January 2018; 2799 intervention and sustain: February 2018 to June 2020). The outcome measure displayed iterative special cause variation from a mean baseline of 7% to peak of 39% but regressed and was sustained at 27%. The process measure displayed iterative special cause variation from a 13% baseline mean to a 64% peak, with regression to 41%. The balancing measure worsened from baseline of 5% dissatisfaction to 13%. Interventions temporally related to special cause improvements were education, division-level performance feedback, standardization of documentation, and offloading the task of communication coordination from hospitalists to support staff. CONCLUSIONS Improvement methodology resulted in modestly sustained improvements in PCP communication for high-risk discharges from the PHM services.
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Affiliation(s)
- Nicholas A Clark
- Division of Hospital Medicine
- School of Medicine, University of Missouri-Kansas City
| | - Julia Simmons
- Mercy Children's Hospital St Louis, St Louis, Missouri
| | - Angela Etzenhouser
- Division of Hospital Medicine
- School of Medicine, University of Missouri-Kansas City
- Graduate Medical Education, Department of Pediatrics, Children's Mercy Kansas City, Kansas City, Missouri
| | - Eugenia K Pallotto
- Division of Neonatology, Department of Pediatrics, Atrium Health Levine Children's Hospital, Charlotte, North Carolina
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20
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Osorio SN, Gage S, Mallory L, Soung P, Satty A, Abramson EL, Provost L, Cooperberg D. Factorial Analysis Quantifies the Effects of Pediatric Discharge Bundle on Hospital Readmission. Pediatrics 2021; 148:peds.2021-049926. [PMID: 34593650 DOI: 10.1542/peds.2021-049926] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Factorial design of a natural experiment was used to quantify the benefit of individual and combined bundle elements from a 4-element discharge transition bundle (checklist, teach-back, handoff to outpatient providers, and postdischarge phone call) on 30-day readmission rates (RRs). METHODS A 24 factorial design matrix of 4 bundle element combinations was developed by using patient data (N = 7725) collected from January 2014 to December 2017 from 4 hospitals. Patients were classified into 3 clinical risk groups (CRGs): no chronic disease (CRG1), single chronic condition (CRG2), and complex chronic condition (CRG3). Estimated main effects of each bundle element and their interactions were evaluated by using Study-It software. Because of variation in subgroup size, important effects from the factorial analysis were determined by using weighted effect estimates. RESULTS RR in CRG1 was 3.5% (n = 4003), 4.1% in CRG2 (n = 1936), and 17.6% in CRG3 (n = 1786). Across the 3 CRGs, the number of subjects in the factorial groupings ranged from 16 to 674. The single most effective element in reducing RR was the checklist in CRG1 and CRG2 (reducing RR by 1.3% and 3.0%) and teach-back in CRG3 (by 4.7%) The combination of teach-back plus a checklist had the greatest effect on reducing RR in CRG3 by 5.3%. CONCLUSIONS The effect of bundle elements varied across risk groups, indicating that transition needs may vary on the basis of population. The combined use of teach-back plus a checklist had the greatest impact on reducing RR for medically complex patients.
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Affiliation(s)
- Snezana Nena Osorio
- Department of Pediatrics, Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
| | - Sandra Gage
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin.,Department of Child Health, College of Medicine-Phoenix, University of Arizona and Phoenix Children's Hospital, Phoenix, Arizona
| | - Leah Mallory
- Department of Pediatrics, School of Medicine, Tufts University and The Barbara Bush Children's Hospital, Portland, Maine
| | - Paula Soung
- Department of Pediatrics, Medical College of Wisconsin and Children's Hospital of Wisconsin, Milwaukee, Wisconsin
| | - Alexandra Satty
- Department of Pediatrics, Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
| | - Erika L Abramson
- Department of Pediatrics, Weill Cornell Medical College and New York Presbyterian Hospital, New York, New York
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21
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Pugh K, Granger D, Lusk J, Feaster W, Weiss M, Wright D, Ehwerhemuepha L. Targeted Clinical Interventions for Reducing Pediatric Readmissions. Hosp Pediatr 2021; 11:1151-1163. [PMID: 34535502 DOI: 10.1542/hpeds.2020-005786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND In this interventional study, we addressed the selection and application of clinical interventions on pediatric patients identified as at risk by a predictive model for readmissions. METHODS A predictive model for readmissions was implemented, and a team of providers expanded corresponding clinical interventions for at-risk patients at a freestanding children's hospital. Interventions encompassed social determinants of health, outpatient care, medication reconciliation, inpatient and discharge planning, and postdischarge calls and/or follow-up. Statistical process control charts were used to compare readmission rates for the 3-year period preceding adoption of the model and clinical interventions with those for the 2-year period after adoption of the model and clinical interventions. Potential financial savings were estimated by using national estimates of the cost of pediatric inpatient readmissions. RESULTS The 30-day all-cause readmission rates during the periods before and after predictive modeling (and corresponding 95% confidence intervals [CI]) were 12.5% (95% CI: 12.2%-12.8%) and 11.1% (95% CI: 10.8%-11.5%), respectively. More modest but similar improvements were observed for 7-day readmissions. Statistical process control charts indicated nonrandom reductions in readmissions after predictive model adoption. The national estimate of the cost of pediatric readmissions indicates an associated health care savings due to reduced 30-day readmission during the 2-year predictive modeling period at $2 673 264 (95% CI: $2 612 431-$2 735 364). CONCLUSIONS A combination of predictive modeling and targeted clinical interventions to improve the management of pediatric patients at high risk for readmission was successful in reducing the rate of readmission and reducing overall health care costs. The continued prioritization of patients with potentially modifiable outcomes is key to improving patient outcomes.
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Affiliation(s)
- Karen Pugh
- Children's Health of Orange County, Orange, California
| | - David Granger
- Children's Health of Orange County, Orange, California
| | - Jennifer Lusk
- Children's Health of Orange County, Orange, California
| | | | - Michael Weiss
- Children's Health of Orange County, Orange, California
| | | | - Louis Ehwerhemuepha
- Children's Health of Orange County, Orange, California .,Schmid College of Science and Technology, Chapman University, Orange, California
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22
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Reducing Time to Discharge after Chemotherapy by Standardizing Workflow and Providing Outpatient Intravenous Hydration. Pediatr Qual Saf 2021; 6:e415. [PMID: 34235346 PMCID: PMC8225375 DOI: 10.1097/pq9.0000000000000415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Accepted: 12/09/2020] [Indexed: 11/25/2022] Open
Abstract
Introduction Patients receiving cyclophosphamide or ifosfamide chemotherapy require intravenous fluid hydration to prevent hemorrhagic cystitis. In selected patients without medical contraindications (ie, excess nausea/vomiting), this hydration may be completed after discharge. We aimed to reduce the time to discharge after completing mesna in patients receiving cyclophosphamide or ifosfamide therapy on an inpatient chemotherapy service. Methods The quality improvement team performed a medical record review to capture the time to discharge after mesna therapy and the readmission rate and used quality improvement methods to redesign discharge workflow and increase patient involvement with the discharge process. Results From August 2017 through July 2018, there were 160 admission encounters (73 patients) for cyclophosphamide or ifosfamide on a dedicated chemotherapy service. Of those encounters, 89 (55.6%) were appropriate for outpatient hydration; 48 (53.9%) of these encounters involved a patient who elected to receive outpatient hydration. Although the median time to discharge for the whole cohort did not change, in encounters where patients chose intravenous outpatient hydration, the median time to discharge was reduced from 2.82 to 0.66 hours (76.6% reduction) after implementing the new discharge workflow. No patients experienced readmission within 48 hours. Conclusions Discharge workflow redesign and standardization reduced the time to discharge after chemotherapy in patients who chose outpatient hydration. Outpatient intravenous hydration after cyclophosphamide or ifosfamide appears safe and feasible in selected patient populations.
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23
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Uong A, Philips K, Hametz P, Dunbar J, Jain P, O’Connor K, Offenbacher R, Eliezer K, Pilnick C, Kiely V, Rinke ML. SAFER Care: Improving Caregiver Comprehension of Discharge Instructions. Pediatrics 2021; 147:peds.2020-0031. [PMID: 33707198 PMCID: PMC8015156 DOI: 10.1542/peds.2020-0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND One in five pediatric patients suffers from adverse events related to hospital discharge. Current literature lacks evidence on effective interventions to improve caregiver comprehension (CC) of discharge instructions. We examined if a standardized framework for written and verbal discharge counseling was associated with increased CC of key discharge instructions after discharge from a general pediatric inpatient unit. METHODS An interprofessional team created the SAFER Care framework to encourage standard, comprehensive discharge counseling. Plan-do-study-act cycles included electronic health record smartphrases, educational initiatives, data feedback, visual aids, and family outreach. Caregivers were surveyed by phone within 4 days of discharge. Our primary outcome was the proportion of caregivers correctly responding to all questions related to discharge care, comparing pre- and postintervention periods. Data were plotted on a statistical process control chart to assess the effectiveness of interventions. RESULTS A total of 171 surveys were analyzed in the preintervention period, and 262 surveys were analyzed in the postintervention period. A total of 37% of caregivers correctly responded to all questions in the preintervention period, compared with 62% of caregivers in the postintervention period, meeting rules for special cause variation. CONCLUSIONS Development of the SAFER Care framework and its use in written and verbal discharge counseling was associated with significantly improved CC of discharge instructions in a general pediatric inpatient unit. Further studies should be focused on expanding this to other populations, particularly limited-English-proficiency families.
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Affiliation(s)
- Audrey Uong
- Children's Hospital at Montefiore, Bronx, New York; and .,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Kaitlyn Philips
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Patricia Hametz
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Julie Dunbar
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Priya Jain
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Katherine O’Connor
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | | | | | | | | | - Michael L. Rinke
- Children’s Hospital at Montefiore, Bronx, New York; and,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
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Philips K, Zhou R, Lee DS, Marrese C, Nazif J, Browne C, Sinnett M, Tuckman S, Modi A, Rinke ML. Implementation of a Standardized Approach to Improve the Pediatric Discharge Medication Process. Pediatrics 2021; 147:peds.2019-2711. [PMID: 33408070 PMCID: PMC7849199 DOI: 10.1542/peds.2019-2711] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/23/2020] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The pediatric inpatient discharge medication process is complicated, and caregivers have difficulty managing instructions. Authors of few studies evaluate systematic processes for ensuring quality in these care transitions. We aimed to improve caregiver medication management and understanding of discharge medications by standardizing the discharge medication process. METHODS An interprofessional team at an urban, tertiary care children's hospital trialed interventions to improve caregiver medication management and understanding. These included mnemonics to aid in complete medication counseling, electronic medical record enhancements to standardize medication documentation and simplify dose rounding, and housestaff education. The primary outcome measure was the proportion of discharge medication-related failures in each 4-week period. Failure was defined as an incorrect response on ≥1 survey questions. Statistical process control was used to analyze improvement over time. Process measures related to medication documentation and dose rounding were compared by using the χ2 test and process control. RESULTS Special cause variation occurred in the mean discharge medication-related failure rate, which decreased from 70.1% to 36.1% and was sustained. There were significantly more complete after-visit summaries (21.0% vs 85.1%; P < .001) and more patients with simplified dosing (75.2% vs 95.6%; P < .001) in the intervention period. Special cause variation also occurred for these measures. CONCLUSIONS A systematic approach to standardizing the discharge medication process led to improved caregiver medication management and understanding after pediatric inpatient discharge. These changes could be adapted by other hospitals to enhance the quality of this care transition.
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Affiliation(s)
- Kaitlyn Philips
- Children's Hospital at Montefiore, Bronx, New York; .,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | - Roy Zhou
- NewYork-Presbyterian Queens Hospital, Flushing, New York
| | - Diana S. Lee
- Mount Sinai Kravis Children’s Hospital, New York, New York; and
| | - Christine Marrese
- Baystate Children’s Hospital, Baystate Medical Center, Springfield, Massachusetts
| | - Joanne Nazif
- Children’s Hospital at Montefiore, Bronx, New York;,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
| | | | - Mark Sinnett
- Children’s Hospital at Montefiore, Bronx, New York
| | | | - Anjali Modi
- Children’s Hospital at Montefiore, Bronx, New York
| | - Michael L. Rinke
- Children’s Hospital at Montefiore, Bronx, New York;,Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York
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Logsdon KD, Little JM. Evaluation of Discharge Coordinators and Their Effect on Discharge Efficiency and Preparedness. J Pediatr Health Care 2020; 34:435-441. [PMID: 32593500 DOI: 10.1016/j.pedhc.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2020] [Revised: 04/17/2020] [Accepted: 04/18/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION A discharge coordinator role was evaluated to determine if it resulted in more discharges before noon, decreased length of stay, and prepared families for self-care at home. METHOD This evaluation took place at a pediatric cardiac care unit. Discharges before noon, reasons for delays, and length of stay were analyzed before and after the discharge coordinator role. Parental knowledge assessments were completed a week after discharge. A nursing survey measured satisfaction with the patient discharge process. RESULTS Rates of discharge before noon increased (31.68% vs. 44.39%) and length of stay decreased (97.16 vs. 85.24 hr) with a discharge coordinator. Parental knowledge assessment revealed fewer deficits, and nurses were satisfied. DISCUSSION A dedicated person to coordinate patient discharge needs can improve discharge efficiency and increase the likelihood of successful self-care at home. Further evaluation is needed to determine how this role impacts readmission.
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Timely Delivery of Discharge Medications to Patients' Bedsides: A Patient-centered Quality Improvement Project. Pediatr Qual Saf 2020; 5:e297. [PMID: 32607457 PMCID: PMC7297402 DOI: 10.1097/pq9.0000000000000297] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Accepted: 04/14/2020] [Indexed: 11/29/2022] Open
Abstract
Introduction: Patients who are unable to fill prescriptions after discharge are at risk of hospital readmission. Ensuring that patients have prescriptions in hand at the time of discharge is a critical component of a safe and effective discharge process. Using a “Meds to Beds” program, we aimed to increase the percentage of patients discharged from Holtz Children’s Hospital with medications in hand from 49% to 80%, reduce turnaround time (TAT) from electronic prescription signature to bedside delivery from 4.9 hours (±2.6 hours) to 2 hours, and increase caregiver satisfaction. Methods: We formed a multidisciplinary team and implemented 4 patient-centered interventions through iterative plan-do-study-act cycles. Statistical process control charts were used to understand the impact of the interventions over 10 months. Hospital length of stay and discharges before 2:00 pm were used as balancing measures. We measured caregiver satisfaction using a telephone survey administered by pediatric residents within 7 days after discharge. Results: The mean percentage of patients discharged with medications in hand increased to 76%. TAT decreased to 3.5 hours (±1.8 hours). Length of stay did not significantly increase, whereas the percentage of patients discharged before 2:00 pm did. Caregivers of patients who had prescriptions delivered to their bedside reported high levels of satisfaction. Conclusions: Using a “Meds to Beds” program, we increased the percentage of patients discharged with medications in hand, decreased TAT with reduced variability, and achieved high levels of caregiver satisfaction. Importantly, there was a shift in the culture of the institution toward improved medication access for patients.
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Brittan MS, Campagna EJ, Keller D, Kempe A. How Measurement Variability Affects Reporting of a Single Readmission Metric. J Healthc Qual 2020; 41:160-164. [PMID: 31094949 DOI: 10.1097/jhq.0000000000000152] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Readmissions are an important quality measure for public reporting, payment, and collaborative research. Lack of measure standardization may lead to inconsistent reporting of outcomes across study sites. In this study, we examined the impact of measurement variability on reporting of a single readmission metric, 30-day all-condition readmission rates (ARRs). We conducted a secondary database analysis of 2006-2008 Medicaid Analytic eXtract data merged from four states of children younger than 21 years. We calculated 30-day ARRs for this cohort using three previously described models varying in their inclusions and exclusions of index hospitalizations and readmissions. The 30-day ARR was highest for the model allowing each readmission to serve as an index admission for subsequent readmissions (ARR: 7%); intermediate for the model allowing one index admission and more than one readmissions in each 30-day period (ARR: 6.2%); and lowest for the model allowing only one readmission in each 30-day period (ARR: 5.6%). Similar variation was seen when stratifying patients by individual diagnostic groups. In conclusion, measurement variability impacts reported outcomes of a single readmission metric. To improve the value of readmission as a quality metric, stakeholders engaged in multisite quality improvement or research should ensure that definitions are standardized across sites.
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28
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Litt JS, Edwards EM, Lainwala S, Mercier C, Montgomery A, O’Reilly D, Rhein L, Woythaler M, Hartman T. Optimizing High-risk Infant Follow-up in Nonresearch-based Paradigms: The New England Follow-up Network. Pediatr Qual Saf 2020; 5:e287. [PMID: 32656462 PMCID: PMC7297406 DOI: 10.1097/pq9.0000000000000287] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 03/18/2020] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVES To establish the first regional quality improvement collaborative solely dedicated to follow-through care of high-risk infants after Neonatal intensive care unit (NICU) discharge and to characterize extremely low birth weight (ELBW) follow-up in New England. METHODS Eleven of 14 follow-up programs in New England partnered with the Vermont Oxford Network (VON) ELBW project for an initial data collection project. We collected information about the health status and developmental outcomes of infants born ≤1,000 g or younger than 28 weeks 2014-2016 at the 18-24 months corrected for gestational age (CGA) follow-up visit. VON collected and compiled the data. RESULTS Of 993 eligible infants, 516 (52.0%) had follow-up visits. The rehospitalization rate was 33.9%, mostly respiratory illness. Ninety-six children (19.3%) had weight less than 10th percentile and 44 (8.9%) had weight less than third percentile at 18-24 months. Only 170 (61.4%) children had recommended hearing screening after NICU discharge. Forty-six (9.1%) had cerebral palsy; 81 of the 441 infants that completed all 3 sections of the Bayley Scales of Infant Development, third edition (18.4%) had any composite score less than 70. Over half of the social and demographic data were missing. CONCLUSION Most quality initiatives in neonatology stop at NICU discharge. This first project by the New England Follow-up Network showed a low rate for clinical follow-up. It demonstrated many opportunities to improve postdischarge follow-through specific to NICU-based care. Future projects will aim to improve the quality of follow-through services through collaborative learning, data sharing, and comparative outcomes.
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Affiliation(s)
- Jonathan S. Litt
- From the Department of Neonatology, Beth Israel Deaconess Medical Center, Boston, Mass
| | | | - Shabnam Lainwala
- Division of Neonatology, Connecticut Children’s Hospital, Hartford, Conn
| | - Charles Mercier
- Vermont Oxford Network, Burlington, Vt
- Division of Neonatology, University of Vermont Medical Center, Burlington, Vt
| | - Angela Montgomery
- Division of Neonatology, Yale-New Haven Children’s Hospital, New Haven, Conn
| | - Deirdre O’Reilly
- Division of Neonatology, University of Vermont Medical Center, Burlington, Vt
| | - Lawrence Rhein
- Division of Neonatology, UMASS Memorial Medical Center, Worcester, Mass
| | - Melissa Woythaler
- Division of Neonatology, Massachusetts General Hospital for Children, Boston, Mass
| | - Tyler Hartman
- Division of Neonatology, Children’s Hospital at Dartmouth, Lebanon, N.H
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29
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Taylor T, Altares Sarik D, Salyakina D. Development and Validation of a Web-Based Pediatric Readmission Risk Assessment Tool. Hosp Pediatr 2020; 10:246-256. [PMID: 32075853 DOI: 10.1542/hpeds.2019-0241] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Accurately predicting and reducing risk of unplanned readmissions (URs) in pediatric care remains difficult. We sought to develop a set of accurate algorithms to predict URs within 3, 7, and 30 days of discharge from inpatient admission that can be used before the patient is discharged from a current hospital stay. METHODS We used the Children's Hospital Association Pediatric Health Information System to identify a large retrospective cohort of 1 111 323 children with 1 321 376 admissions admitted to inpatient care at least once between January 1, 2016, and December 31, 2017. We used gradient boosting trees (XGBoost) to accommodate complex interactions between these predictors. RESULTS In the full cohort, 1.6% of patients had at least 1 UR in 3 days, 2.4% had at least 1 UR in 7 days, and 4.4% had at least 1 UR within 30 days. Prediction model discrimination was strongest for URs within 30 days (area under the curve [AUC] = 0.811; 95% confidence interval [CI]: 0.808-0.814) and was nearly identical for UR risk prediction within 3 days (AUC = 0.771; 95% CI: 0.765-0.777) and 7 days (AUC = 0.778; 95% CI: 0.773-0.782), respectively. Using these prediction models, we developed a publicly available pediatric readmission risk scores prediction tool that can be used before or during discharge planning. CONCLUSIONS Risk of pediatric UR can be predicted with information known before the patient's discharge and that is easily extracted in many electronic medical record systems. This information can be used to predict risk of readmission to support hospital-discharge-planning resources.
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Affiliation(s)
- Thom Taylor
- Nicklaus Children's Research Institute, .,Nicklaus Children's Health System, Miami, Florida; and.,Research Facilitation Laboratory, Northrop Grumman, Monterey, California
| | | | - Daria Salyakina
- Nicklaus Children's Research Institute.,Nicklaus Children's Health System, Miami, Florida; and
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30
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Desai AD, Zhou C, Simon TD, Mangione-Smith R, Britto MT. Validation of a Parent-Reported Hospital-to-Home Transition Experience Measure. Pediatrics 2020; 145:e20192150. [PMID: 31969474 PMCID: PMC6993281 DOI: 10.1542/peds.2019-2150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/13/2019] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES The Pediatric Transition Experience Measure (P-TEM) is an 8-item, parent-reported measure that globally assesses hospital-to-home transition quality from discharge through follow-up. Our goal was to examine the convergent validity of the P-TEM with existing, validated process and outcome measures of pediatric hospital-to-home transitions. METHODS This was a prospective, cohort study of English-speaking parents and legal guardians who completed the P-TEM after their children's discharge from a tertiary children's hospital between January 2016 and October 2016. By using data from 3 surveys, we assessed convergent validity by examining associations between total and domain-specific P-TEM scores (0-100 scale) and 4 pediatric hospital-to-home transition validation measures: (1) Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite, (2) Center of Excellence on Quality of Care Measures for Children With Complex Needs parent-reported transition measures, (3) change in health-related quality of life from admission to postdischarge, and (4) 30-day emergency department revisits or readmissions. RESULTS P-TEM total scores were 7.5 points (95% confidence interval: 4.6 to 10.4) higher for participants with top-box responses on the Child Hospital Consumer Assessment of Healthcare Providers and Systems Discharge Composite compared with those of participants with lower Discharge Composite scores. Participants with highet P-TEM scores (ie, top-box responses) had 6.3-points-greater improvement (95% confidence interval: 2.8 to 9.8) in health-related quality of life compared with participants who reported lower P-TEM scores. P-TEM scores were not significantly associated with 7- or 30-day reuse. CONCLUSIONS The P-TEM demonstrated convergent validity with existing hospital-to-home process and outcome validation measures in a population of hospitalized children.
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Affiliation(s)
- Arti D Desai
- Department of Pediatrics, University of Washington, Seattle, Washington;
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Chuan Zhou
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Tamara D Simon
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Rita Mangione-Smith
- Department of Pediatrics, University of Washington, Seattle, Washington
- Seattle Children's Research Institute, Seattle, Washington; and
| | - Maria T Britto
- James M. Anderson Center for Health Systems Excellence, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
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31
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Philips K, Zhou R, Lee DS, Marrese C, Nazif J, Browne C, Sinnett M, Tuckman S, Griffith K, Kiely V, Lutz M, Modi A, Rinke ML. Caregiver Medication Management and Understanding After Pediatric Hospital Discharge. Hosp Pediatr 2019; 9:844-850. [PMID: 31582401 PMCID: PMC6818354 DOI: 10.1542/hpeds.2019-0036] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Caregivers frequently make mistakes when following instructions on discharge medications, and these instructions often contain discrepancies. Minimal literature reflects inpatient discharges. Our objective was to describe failures in caregiver management and understanding of inpatient discharge medications and to test the association of documentation discrepancies and sociodemographic factors with medication-related failures after an inpatient hospitalization. METHODS This study took place in an urban tertiary care children's hospital that serves a low-income, minority population. English-speaking caregivers of children discharged on an oral prescription medication were surveyed about discharge medication knowledge 48 to 96 hours after discharge. The primary outcome was the proportion of caregivers who failed questions on a 10-item questionnaire (analyzed as individual question responses and as a composite outcome of any discharge medication-related failure). Bivariate tests were used to compare documentation errors, complex dosing, and sociodemographic factors to having any discharge medication-related failure. RESULTS Of 157 caregivers surveyed, 70% had a discharge medication-related failure, most commonly because of lack of knowledge about side effects (52%), wrong duration (17%), and wrong start time (16%). Additionally, 80% of discharge instructions provided to caregivers lacked integral medication information, such as duration or when the next dose after discharge was due. Twenty five percent of prescriptions contained numerically complex doses. In bivariate testing, only race and/or ethnicity was significantly associated with having any failure (P = .03). CONCLUSIONS The majority of caregivers had a medication-related failure after discharge, and most discharge instructions lacked key medication information. Future work to optimize the discharge process to support caregiver management and understanding of medications is needed.
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Affiliation(s)
- Kaitlyn Philips
- Children's Hospital at Montefiore, Bronx, New York;
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; and
| | - Roy Zhou
- Children's Hospital at Montefiore, Bronx, New York
| | - Diana S Lee
- Children's Hospital at Montefiore, Bronx, New York
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; and
| | | | - Joanne Nazif
- Children's Hospital at Montefiore, Bronx, New York
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; and
| | | | - Mark Sinnett
- Children's Hospital at Montefiore, Bronx, New York
| | | | | | | | - Marcia Lutz
- Children's Hospital at Montefiore, Bronx, New York
| | - Anjali Modi
- Children's Hospital at Montefiore, Bronx, New York
| | - Michael L Rinke
- Children's Hospital at Montefiore, Bronx, New York
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, New York; and
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Abstract
Health literacy plays a role in the events leading up to children's hospitalizations, during hospital admission, and after discharge. Hospitals and providers should use a universal precautions approach and routinely incorporate health-literacy-informed strategies in communicating with all patients and families to ensure that they can understand health information, follow medical instructions, participate actively in their own/their child's care, and successfully navigate the health care system. Interventions that incorporate health-literacy-informed strategies and that target patients/families and health care systems should be implemented to improve patient outcomes and patient-centered and family-centered care.
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Chadwick W, Bassett H, Hendrickson S, Slonaker K, Perales S, Pantaleoni J, Srinivas N, Platchek T, Destino L. An Improvement Effort to Optimize Electronically Generated Hospital Discharge Instructions. Hosp Pediatr 2019; 9:523-529. [PMID: 31243058 DOI: 10.1542/hpeds.2018-0251] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
OBJECTIVES The purpose of hospital discharge instructions (HDIs) is to facilitate safe patient transitions home, but electronic health records can generate lengthy documents filled with irrelevant information. When our institution changed electronic health records, a cumbersome electronic discharge workflow produced low-value HDI and contributed to a spike in discharge delays. Our aim was to decrease these delays while improving family and provider satisfaction with HDI. METHODS We used quality improvement methodology to redesign the electronic discharge navigator and HDI to address the following issues: (1) difficulty preparing discharge instructions before time of discharge, (2) suboptimal formatting of HDI, (3) lack of standard templates and language within HDI, and (4) difficulties translating HDI into non-English languages. Discharge delays due to HDI were tracked before and after the launch of our new discharge workflow. Parents and providers evaluated HDI and the electronic discharge workflow, respectively, before and after our intervention. Providers audited HDI for content. RESULTS Discharge delays due to HDI errors decreased from a mean of 3.4 to 0.5 per month after our intervention. Parents' ratings of how understandable our HDIs were improved from 2.35 to 2.74 postintervention (P = .05). Pediatric resident agreement that the electronic discharge process was easy to use increased from 9% to 67% after the intervention (P < .001). CONCLUSIONS Through multidisciplinary collaboration we facilitated advance preparation of more standardized HDI and decreased related discharge delays from the acute care units at a large tertiary care hospital.
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Affiliation(s)
- Whitney Chadwick
- Divisions of Pediatric Hospital Medicine and
- Departments of Clinical Informatics and
- Performance Improvement, Stanford Children's Health, Palo Alto, California
| | | | - Sarah Hendrickson
- Massachusetts General Hospital for Children and Harvard Medical School, Harvard University, Boston, Massachusetts; and
| | - Kimberly Slonaker
- Department of Pediatrics, Kaiser Permanente Northern California, Santa Clara, California
| | | | | | - Nivedita Srinivas
- Divisions of Pediatric Hospital Medicine and
- Pediatric Infectious Disease, School of Medicine, and
| | - Terry Platchek
- Divisions of Pediatric Hospital Medicine and
- Performance Improvement, Stanford Children's Health, Palo Alto, California
- Clinical Excellence Research Center, Stanford University, Stanford, California
| | - Lauren Destino
- Divisions of Pediatric Hospital Medicine and
- Performance Improvement, Stanford Children's Health, Palo Alto, California
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Platter E, Hamline MY, Tancredi DJ, Fernandez Y Garcia E, Rosenthal JL. Completeness of Written Discharge Guidance for English- and Spanish-Speaking Patient Families. Hosp Pediatr 2019; 9:516-522. [PMID: 31182648 DOI: 10.1542/hpeds.2018-0250] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES Written discharge guidance for hospitalized pediatric patients should include language-appropriate key elements to ensure positive discharge outcomes. Our objective in this study was to determine the completeness of written pediatric discharge guidance and to test the hypothesis that Spanish-speaking families with limited English proficiency (LEP) receive less complete written discharge guidance than English-speaking families. METHODS We conducted a retrospective review of written discharge guidance provided to 100 English- and 100 Spanish-speaking families at an urban nonfreestanding children's hospital to assess the inclusion of key elements: follow-up plan, contingency plan, telephone contact, discharge medications, discharge diagnosis, and hospital course. We compared the completeness of discharge guidance (number of elements provided among number of applicable elements) between English- versus Spanish-speaking families. RESULTS When evaluating discharge guidance for the presence of key elements in any language, there was no significant difference between English- and Spanish-speaking families. However, the mean completeness of language-appropriate discharge guidance for English- and Spanish-speaking families was 87.8% (95% confidence interval [CI] 84.4%-91.1%) and 16.0% (95% CI 11.5%-20.4%), respectively. The ordinal logistic regression examining the association between the number of key element deficits and English- (reference group) versus Spanish-speaking families demonstrated an adjusted odds ratio of 339.8 (95% CI 112.4-1027.5). CONCLUSIONS Few Spanish-speaking families with LEP receive written discharge guidance in their preferred language. Complete, language-appropriate discharge guidance was identified as an area for improvement efforts to work toward improving care provided to families with LEP.
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Affiliation(s)
- Erin Platter
- Department of Pediatrics, University of Virginia, Charlottesville, Virginia; and
| | - Michelle Y Hamline
- Department of Pediatrics, University of California, Davis, Sacramento, California
| | - Daniel J Tancredi
- Department of Pediatrics, University of California, Davis, Sacramento, California
| | | | - Jennifer L Rosenthal
- Department of Pediatrics, University of California, Davis, Sacramento, California
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Martens A, DeLucia M, Leyenaar JK, Mallory LA. Foster Caregiver Experience of Pediatric Hospital-to-Home Transitions: A Qualitative Analysis. Acad Pediatr 2018; 18:928-934. [PMID: 30401467 DOI: 10.1016/j.acap.2018.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Revised: 06/01/2018] [Accepted: 06/16/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Children entering foster care after discharge from the hospital are at risk for adverse events associated with the hospital-to-home transition. Education of foster caregivers regarding transitional care needs is key. However, little is known about the unique needs of foster caregivers as they transition from hospital to home with a new foster child or how hospital-based health care teams can better support foster caregivers. We aimed to examine the experiences and preferences of foster caregivers' regarding hospital-to-home transitions of children newly discharged into their care and to identify opportunities for inpatient providers to improve outcomes for these children. METHODS We conducted semistructured telephone interviews of foster caregivers who newly assumed care of a child at the time of hospital discharge between May 2016 and June 2017. Interviews were continued until thematic saturation was reached. Interviews were audio recorded, transcribed, and analyzed to identify themes using a general inductive approach. RESULTS Fifteen interviews were completed. All subjects were female, 87% were Caucasian, and 73% were first-time foster caregivers. Thirteen themes were identified and grouped into the following domains: 1) knowing the child, 2) medicolegal issues, 3) complexities of multistakeholder communication, and 4) postdischarge preparation and support. CONCLUSIONS Caregivers of children newly entering foster care following hospital discharge face unique challenges and may benefit from enhanced care processes to facilitate successful transitions. Hospitalization provides an opportunity for information gathering and sharing, clarification of custodial status, and facilitation of communication among multistakeholders, including child protective services and biological parents.
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Affiliation(s)
- Anna Martens
- Tufts University School of Medicine (A Martens and M DeLucia), Boston, Mass
| | - Michael DeLucia
- Tufts University School of Medicine (A Martens and M DeLucia), Boston, Mass
| | - JoAnna K Leyenaar
- Department of Pediatrics, Dartmouth-Hitchcock Medical Center and Dartmouth Institute for Health Policy and Clinical Practice (JK Leyenaar), Lebanon, NH
| | - Leah A Mallory
- Department of Pediatrics, The Barbara Bush Children's Hospital at Maine Medical Center (LA Mallory), Portland, Me.
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36
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Hamline MY, Speier RL, Vu PD, Tancredi D, Broman AR, Rasmussen LN, Tullius BP, Shaikh U, Li STT. Hospital-to-Home Interventions, Use, and Satisfaction: A Meta-analysis. Pediatrics 2018; 142:e20180442. [PMID: 30352792 PMCID: PMC6317574 DOI: 10.1542/peds.2018-0442] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2018] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Hospital-to-home transitions are critical opportunities to promote patient safety and high-quality care. However, such transitions are often fraught with difficulties associated with increased health care use and poor patient satisfaction. OBJECTIVE In this review, we determine which pediatric hospital discharge interventions affect subsequent health care use or parental satisfaction compared with usual care. DATA SOURCES We searched 7 bibliographic databases and 5 pediatric journals. STUDY SELECTION Inclusion criteria were: (1) available in English, (2) focused on children <18 years of age, (3) pediatric data reported separately from adult data, (4) not focused on normal newborns or pregnancy, (5) discharge intervention implemented in the inpatient setting, and (6) outcomes of health care use or caregiver satisfaction. Reviews, case studies, and commentaries were excluded. DATA EXTRACTION Two reviewers independently abstracted data using modified Cochrane data collection forms and assessed quality using modified Downs and Black checklists. RESULTS Seventy one articles met inclusion criteria. Although most interventions improved satisfaction, interventions variably reduced use. Interventions focused on follow-up care, discharge planning, teach back-based parental education, and contingency planning were associated with reduced use across patient groups. Bundled care coordination and family engagement interventions were associated with lower use in patients with chronic illnesses and neonates. LIMITATIONS Variability limited findings and reduced generalizability. CONCLUSIONS In this review, we highlight the utility of a pediatric discharge bundle in reducing health care use. Coordinating follow-up, discharge planning, teach back-based parental education, and contingency planning are potential foci for future efforts to improve hospital-to-home transitions.
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Affiliation(s)
| | | | - Paul Dai Vu
- School of Aerospace Medicine, Wright-Patterson Air Force Base, United States Air Force, Dayton, Ohio
| | | | - Alia R Broman
- Department of Pediatrics, Oregon Health and Science University, Portland, Oregon; and
| | | | - Brian P Tullius
- Department of Pediatric Hematology, Oncology, and Bone Marrow Transplant, Nationwide Children's Hospital, Columbus, Ohio
| | - Ulfat Shaikh
- Department of Pediatrics
- School of Medicine, University of California, Davis, Sacramento, California
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Auger KA, Shah SS, Tubbs-Cooley HL, Sucharew HJ, Gold JM, Wade-Murphy S, Statile AM, Bell KD, Khoury JC, Mangeot C, Simmons JM. Effects of a 1-Time Nurse-Led Telephone Call After Pediatric Discharge: The H2O II Randomized Clinical Trial. JAMA Pediatr 2018; 172:e181482. [PMID: 30039161 PMCID: PMC6143054 DOI: 10.1001/jamapediatrics.2018.1482] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 04/21/2018] [Indexed: 11/14/2022]
Abstract
Importance Families often struggle after discharge of a child from the hospital. Postdischarge challenges can lead to increased use of urgent health care services. Objective To determine whether a single nurse-led telephone call after pediatric discharge decreased the 30-day reutilization rate for urgent care services and enhanced overall transition success. Design, Setting, and Participants This Hospital-to-Home Outcomes (H2O) randomized clinical trial included 966 children and adolescents younger than 18 years (hereinafter referred to as children) admitted to general medicine services at a free-standing tertiary care children's hospital from May 11 through October 31, 2016. Data were analyzed as intention to treat and per protocol. Interventions A postdischarge telephone call within 4 days of discharge compared with standard discharge. Main Outcomes and Measures The primary outcome was the 30-day reutilization rate for urgent health care services (ie, unplanned readmission, emergency department visit, or urgent care visit). Secondary outcomes included additional utilization measures, as well as parent coping, return to normalcy, and understanding of clinical warning signs measured at 14 days. Results A total of 966 children were enrolled and randomized (52.3% boys; median age [interquartile range], 2.4 years [0.5-7.8 years]). Of 483 children randomized to the intervention, the nurse telephone call was completed for 442 (91.5%). Children in the intervention and control arms had similar reutilization rates for 30-day urgent health care services (intervention group, 77 [15.9%]; control group, 63 [13.1%]; P = .21). Parents of children in the intervention group recalled more clinical warning signs at 14 days (mean, 1.8 [95% CI, 1.7-2.0] in the intervention group; 1.5 [95% CI, 1.4-1.6] in the control group; ratio of intervention to control, 1.2 [95% CI, 1.1-1.3]). Conclusions and Relevance Although postdischarge nurse contact did not decrease the reutilization rate of postdischarge urgent health care services, this method shows promise to bolster postdischarge education. Trial Registration ClinicalTrials.gov Identifier: NCT02081846.
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Affiliation(s)
- Katherine A. Auger
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health System Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Samir S. Shah
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health System Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Heather L. Tubbs-Cooley
- Department of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- College of Nursing, Ohio State University, Columbus
| | - Heidi J. Sucharew
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jennifer M. Gold
- Department of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Susan Wade-Murphy
- Department of Patient Services, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Angela M. Statile
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
| | - Kathleen D. Bell
- Northeast Node of the National Drug Abuse Clinical Trials Network, Center for Technology and Behavioral Health, Geisel School of Medicine, Dartmouth College, Lebanon, New Hampshire
| | - Jane C. Khoury
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Colleen Mangeot
- Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Jeffrey M. Simmons
- Division of Hospital Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- James M. Anderson Center for Health System Excellence, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati, Cincinnati, Ohio
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DeLucia M, Martens A, Leyenaar J, Mallory LA. Improving Hospital-to-Home Transitions for Children Entering Foster Care. Hosp Pediatr 2018; 8:465-470. [PMID: 30042218 DOI: 10.1542/hpeds.2017-0221] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND AND OBJECTIVES Hospital-to-home transitions present safety risks for patients. Children discharged with new foster caregivers may be especially vulnerable to poor discharge outcomes. With this study, our objective is to identify differences in discharge quality and outcomes for children discharged from the hospital with new foster caregivers compared with children discharged to their preadmission caregivers. METHODS Pediatric patients discharged from the Barbara Bush Children's Hospital at Maine Medical Center between January 2014 and May 2017 were eligible for inclusion in this retrospective cohort study. Chart review identified patients discharged with new foster caregivers. These patients were compared with a matched cohort of patients discharged with preadmission caregivers for 5 discharge quality process measures and 2 discharge outcomes. RESULTS Fifty-six index cases and 165 matched patients were identified. Index cases had worse performance on 4 of 5 discharge process measures, with significantly lower use of discharge readiness checklists (75% vs 92%; P = .004) and teach-back education of discharge instructions for caregivers (63% vs 79%; P = .02). Index cases had twice the odds of misunderstandings needing clarification at the postdischarge call; this difference was not statistically significant (26% vs 13%; P = .07). CONCLUSIONS Hospital-to-home transition quality measures were less often implemented for children discharged with new foster caregivers than for the cohort of patients discharged with preadmission caregivers. This may lead to increased morbidity, as suggested by more frequent caregiver misunderstandings. Better prospective identification of these patients and enhanced transition improvement efforts targeted at their new caregivers may be warranted.
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Affiliation(s)
| | - Anna Martens
- School of Medicine, Tufts University, Boston, Massachusetts
| | - JoAnna Leyenaar
- Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire.,The Dartmouth Institute for Health Policy and Clinical Practice, Lebanon, New Hampshire; and
| | - Leah A Mallory
- Department of Pediatrics, The Barbara Bush Children's Hospital, Maine Medical Center, Portland, Maine
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Nurse-led Discharge in Pediatric Care: A Scoping Review. J Pediatr Nurs 2018; 41:60-68. [PMID: 29398316 DOI: 10.1016/j.pedn.2018.01.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 01/16/2018] [Accepted: 01/16/2018] [Indexed: 11/24/2022]
Abstract
PROBLEM Patients and caregivers frequently report feeling ill-prepared during the transition from hospital to home. Given the privileged position nurses occupy within the health care setting, they are often an appropriate health care professional to lead the discharge process. We aimed to map what is currently known about nurse-led/facilitated discharge programs, interventions, models, or frameworks for the pediatric population. ELIGIBILITY CRITERIA We conducted a scoping review following the Joanna Briggs Institute Methodology. Published literature targeting children 0-18 years old being discharged from acute care to home and describing a nurse leading the discharge planning/process was included. SAMPLE A search strategy was developed and implemented in four electronic databases; CINAHL, MEDLINE, Embase, and Web of Science. We also hand searched three high impact journals and reviewed reference lists of relevant articles. This search resulted in 1485 records. Based on our eligibility criteria, 9 articles were included in this review. Two independent reviewers screened each eligible article and extracted relevant information. RESULTS Terminology and program structure varied greatly across included studies. Critical appraisal revealed a lack of high quality research designs. CONCLUSIONS We identified a paucity of nurse-led/facilitated discharge programs evaluated within the pediatric population. The majority of studies were inadequately reported, leaving it difficult to identify development, implementation, and evaluation strategies. IMPLICATIONS Given the positive outcomes reported across all articles included in our review, future empirical research is warranted to explore this role within nursing practice.
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Carson SL, Perkins K, Reilly MR, Sim MS, Li STT. Pediatric Program Leadership's Contribution Toward Resident Wellness. Acad Pediatr 2018; 18:550-555. [PMID: 29499379 PMCID: PMC6659726 DOI: 10.1016/j.acap.2018.02.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2017] [Revised: 02/16/2018] [Accepted: 02/19/2018] [Indexed: 01/17/2023]
Abstract
BACKGROUND Residency program leaders are required to support resident well-being, but often they do not receive training in how to do so. OBJECTIVE To determine frequency in which program leadership provides support for resident well-being, comfort in supporting resident well-being, and factors associated with need for additional training in supporting resident well-being. METHODS National cross-sectional web-based survey in June 2015 of pediatric program directors, associate program directors, and coordinators about their experiences supporting resident well-being. Univariate and bivariate descriptive statistics compared responses between groups. Generalized linear modeling, adjusting for program region, size, program leadership role, and number of years in role determined factors associated with need for additional training. RESULTS The response rate was 39.3% (322/820). Most respondents strongly agreed that supporting resident well-being is an important part of their role, but few reported supporting resident well-being as part of their job description. Most reported supporting residents' clinical, personal, and health issues at least annually, and in some cases weekly, with 72% spending >10%of their time on resident well-being. Most program leaders desired more training. After adjusting for level of comfort in dealing with resident well-being issues, program leaders more frequently exposed to resident well-being issues were more likely to desire additional training (P < .02). CONCLUSIONS Program leaders spend a significant amount of time supporting resident well-being. Although they think that supporting resident well-being is an important part of their job, opportunities exist for developing program leaders through including resident wellness on job descriptions and training program leaders how to support resident well-being.
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Affiliation(s)
- Savanna L Carson
- Department of Pediatrics, Mattel Children's Hospital, University of California, Los Angeles, Calif
| | - Kate Perkins
- Department of Pediatrics, Mattel Children's Hospital, University of California, Los Angeles, Calif
| | - Maura R Reilly
- Department of Pediatrics, University of California Davis, Sacramento, Calif
| | - Myung-Shin Sim
- Statistics Core, Department of Medicine, University of California, Los Angeles, Calif
| | - Su-Ting T Li
- Department of Pediatrics, University of California Davis, Sacramento, Calif.
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Statile AM, Unaka N, Auger KA. Preparing from the Outside Looking In for Safely Transitioning Pediatric Inpatients to Home. J Hosp Med 2018; 13:287-288. [PMID: 29394298 DOI: 10.12788/jhm.2935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Angela M Statile
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA.
| | - Ndidi Unaka
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Katherine A Auger
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, and Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
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Mallory LA, Diminick NP, Bourque JP, Bryden MR, Miller JL, Nystrom NM, Lord MR, McElwain LL. Pediatric Patient-Centered Transitions From Hospital to Home: Improving the Discharge Medication Process. Hosp Pediatr 2017; 7:723-730. [PMID: 29114003 DOI: 10.1542/hpeds.2017-0053] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Medications prescribed at hospital discharge can lead to patient harm if there are access barriers or misunderstanding of instructions. Filling prescriptions before discharge can decrease these risks. We aimed to increase the percentage of patients leaving the hospital with new discharge medications in hand to 70% by 18 months. METHODS We used sequential plan-do-study-act cycles from January 2015 to September 2016. We used statistical process control charts to track process measures, new medications filled before discharge, and rates of bedside delivery with pharmacist teaching to the inpatient pediatric unit. Outcome measures included national patient survey data, collected and displayed quarterly, as well as caregiver understanding, comparing inaccuracy of medication teach-back with and without medications in hand before discharge. RESULTS Rates of patients leaving the hospital with medications in hand increased from a baseline of 2% to 85% over the study period. Bedside delivery reached 71%. Inaccuracy of caregiver report during a postdischarge phone call decreased from 3.3% to 0.7% (P < .05) when medications were in hand before discharge. Patient satisfaction with education of new medication side effects increased from 50% to 88%. CONCLUSIONS By using an engaged interprofessional team, we optimized use of our on-site outpatient pharmacy and increased the percentage of pediatric patients leaving the hospital with new discharge medications in hand to >80%. This, accompanied by increased rates of bedside medication delivery and pharmacist teaching, was associated with improvements in caregiver discharge-medication related experience and understanding.
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Affiliation(s)
| | | | | | | | | | - Nancy M Nystrom
- Department of Pharmacy, Maine Medical Center, Portland, Maine
| | - Melanie R Lord
- Nursing, The Barbara Bush Children's Hospital at Maine Medical Center, Portland, Maine; and
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Polites SF, Potter DD, Glasgow AE, Klinkner DB, Moir CR, Ishitani MB, Habermann EB. Rates and risk factors of unplanned 30-day readmission following general and thoracic pediatric surgical procedures. J Pediatr Surg 2017; 52:1239-1244. [PMID: 27956070 DOI: 10.1016/j.jpedsurg.2016.11.043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 11/10/2016] [Accepted: 11/28/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND/PURPOSE Postoperative unplanned readmissions are costly and decrease patient satisfaction; however, little is known about this complication in pediatric surgery. The purpose of this study was to determine rates and predictors of unplanned readmission in a multi-institutional cohort of pediatric surgical patients. METHODS Unplanned 30-day readmissions following general and thoracic surgical procedures in children <18 were identified from the 2012-2014 National Surgical Quality Improvement Program- Pediatric. Time-dependent rates of readmission per 30 person-days were determined to account for varied postoperative length of stay (pLOS). Patients were randomly divided into 70% derivation and 30% validation cohorts which were used for creation and validation of a risk model for readmission. RESULTS Readmission occurred in 1948 (3.6%) of 54,870 children for a rate of 4.3% per 30 person-days. Adjusted predictors of readmission included hepatobiliary procedures, increased wound class, operative duration, complications, and pLOS. The predictive model discriminated well in the derivation and validation cohorts (AUROC 0.710 and 0.701) with good calibration between observed and expected readmission events in both cohorts (p>.05). CONCLUSIONS Unplanned readmission occurs less frequently in pediatric surgery than what is described in adults, calling into question its use as a quality indicator in this population. Factors that predict readmission including type of procedure, complications, and pLOS can be used to identify at-risk children and develop prevention strategies. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | - Amy E Glasgow
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | | | | | | | - Elizabeth B Habermann
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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